Learning objectives.
By reading this article you should be able to:
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Describe the anatomy of the anterior abdominal wall.
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Explain how local anaesthetic in the posterior rectus sheath can provide analgesia for midline laparotomy.
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Compare the pros and cons of different techniques for rectus sheath catheters insertion.
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Recognise the limitations of rectus sheath catheter analgesia including potential complications and adverse effects.
Key points.
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Midline laparotomy is associated with significant pain that may delay recovery.
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Infusion of local anaesthetic by catheter into the posterior rectus sheath can provide effective postoperative analgesia and reduce opioid requirements.
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Rectus sheath catheter analgesia avoids adverse effects associated with thoracic epidural analgesia and may be suitable for patients with contraindications to neuraxial techniques.
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Catheter insertion can be performed by the anaesthetist under ultrasound guidance or by the surgeon at laparotomy.
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Despite increasing popularity in the technique, the optimal method of catheter insertion and local anaesthetic dose regimens are uncertain.
Despite an increase in minimally-invasive abdominal surgical techniques, midline laparotomy is still indicated for a range of elective and emergency procedures. Ideal post-laparotomy analgesia should provide comfort at rest and on movement, and enable early mobilisation, deep breathing, and clearance of secretions in order to reduce associated perioperative complications. Analgesia-related adverse effects that may delay recovery including hypotension, motor block, nausea, vomiting, delirium, and ileus should be minimised.
The management of post-laparotomy pain is evolving, with greater focus on multimodal opioid-sparing techniques including abdominal trunk local anaesthetic (LA) blocks. Effective multi-modal analgesia facilitates early mobilisation and return to function after major surgery and is an important component of Enhanced Recovery After Surgery (ERAS) programmes.
Although outcome data are few, abdominal trunk blocks, including rectus sheath (RS) and transversus abdominis plane (TAP) blocks can provide effective post-laparotomy analgesia whilst avoiding some of the side-effects associated with opioid and thoracic epidural techniques.1, 2, 3 A review of nerve blocks of the abdominal wall was previously published in this journal in 2010.4 This review focuses on the principles and practical applications of RS catheter (RSC) analgesia for abdominal surgery.
Anatomy
Muscles, sheaths, and fascia
The paired rectus abdominis muscles and their anterior and posterior sheaths are the key anatomical landmarks of this block. These muscles arise from the symphysis pubis and pubic tubercle and insert into the fifth, sixth, and seventh costal cartilages and the xiphoid process. The anterior sheath extends from the aponeurosis of the external oblique muscle and the anterior aponeurosis of the internal oblique muscle. The posterior sheath comprises the posterior aponeurosis of the internal oblique muscle and the aponeuroses of the transversus abdominis muscle.5
Innervation of the anterior abdominal wall
Innervation of the anterior abdominal wall arises from the ventral rami of the thoracic nerves (T6–T11), the subcostal nerve (T12), and first lumbar nerve (iliohypogastric and ilioinguinal nerves) (Fig. 1). These segmental nerves travel anteriorly in the neurovascular plane between the internal oblique and transversus abdominis muscles, interconnect widely, and form cutaneous branches that supply skin over the antero-lateral abdominal wall.5 The thoracic nerves continue their course and pierce the RS at its lateral margin to run posterior to the rectus abdominis. The nerves then penetrate the rectus abdominis and the anterior RS to terminate as cutaneous branches that innervate the skin of the anterior abdominal wall from the midline to the mid-clavicular line. Anatomical variation in the passage of these anterior nerves has been described. A cadaveric dye injection study found nerves supplying the upper abdominal wall may pass directly into the rectus muscle near the costal margin and consequently may not be blocked by LA within the posterior RS.6
Fig 1.
The cutaneous branches of lower intercostal and lumbar nerves that supply the skin of the abdominal wall. Reproduced, with permission, from Elsevier.5
Blood supply of the anterior abdominal wall
The inferior and superior epigastric arteries supply blood to the rectus abdominis muscles. The inferior epigastric artery, a branch of the external iliac artery, enters the RS at the level of the arcuate line and ascends between the rectus abdominis muscle and the posterior RS. The superior epigastric artery, a terminal branch of the internal thoracic artery, enters the upper part of the sheath from behind the seventh costal cartilage and travels caudad between the rectus abdominis muscle and the posterior RS. Both arteries form vast anastomoses around the level of T10 and branches traverse the rectus abdominis muscle and perforate the anterior sheath to supply the abdominal skin.5 Blood vessels within the posterior RS can be observed on ultrasound (US) (Fig. 2 online video).
Fig 2.
Doppler US image of anterior abdominal wall. Arrow A: subcutaneous tissue; Arrow B: body of rectus abdominis muscle; Arrow C: artery and vein posterior to rectus abdominis muscle.
Supplementary video related to this article can be found at doi:10.1016/j.bjae.2018.03.002.
The following are the supplementary video related to this article:
US video clip of blood vessels posterior to the rectus abdominis muscle. If reading the pdf online, click on the image to view the video.
Clinical applications
LA within the posterior RS blocks the cutaneous nerves responsible for somatic pain. Unlike epidural analgesia, other analgesic modalities are therefore required to manage visceral pain associated with abdominal surgery. The main application of RSC analgesia is for patients undergoing surgery requiring a midline or para-median abdominal incision. RSCs may not be necessary for small abdominal wall incisions when postoperative pain is likely to be short-lived (e.g. umbilical hernia repair). However, these patients may benefit from a single-injection RS block at the time of surgery.7, 8
Contraindications and cautions
Absolute contraindications to RSC techniques are few and include patient refusal and allergy to LA. Relative contraindications include impaired coagulation and sepsis, but the risk of harm from RSC insertion in patients with these conditions is likely to be less than from neuraxial techniques. RSCs may not be suitable for patients undergoing midline laparotomy for a large incisional hernia repair in which abdominal wall anatomy may be grossly distorted. In such patients, the integrity of the RS may be compromised leading to inadequate spread of LA and unpredictable abdominal wall analgesia.
Complications of RSC analgesia
There are several potential risks of RSC placement and subsequent LA administration (Table 1). However, reports of complications are rare.
Table 1.
Potential complications of rectus sheath catheter analgesia. LA, local anaesthetic; RS, rectus sheath
| Early complications | Later complications |
|---|---|
| Incorrect anatomical placement of catheter and failure of analgesia | Migration of catheter from posterior RS and failure of analgesia |
| Injury to other structures during placement: Blood vessels Peritoneum Bowel |
Systemic LA toxicity: Excess LA absorption from RS Intravascular catheter placement Wrong route error (accidental LA administration into i.v. line) |
| Drug administration error during initial dosing | Catheter blockage |
| Catheter entrapment during abdominal wall closure | Catheter knotting |
| Catheter-related infection | |
| Infusion pump failure |
LA systemic toxicity after RS block
High volumes of LA are generally required for RS blocks and LA systemic toxicity is a potential complication. Toxicity may result from systemic absorption of LA correctly deposited in the posterior RS or from inadvertent vascular administration secondary to intravascular RSC placement, or accidental administration of LA into an i.v. line during subsequent dosing. A recent systematic review of systemic concentrations of LA after TAP and RS blocks found both blocks can lead to systemic concentrations exceeding accepted thresholds of LA systemic toxicity.9 However, only 1% of patients reported symptoms of toxicity, which in each patient were mild and occurred after TAP and not RS blocks. Maximal serum concentration (Cmax) appeared lower and time to Cmax (Tmax) longer in the RS group compared with the TAP group, possibly because the RS is a less vascular fascial plane than the TAP, but the authors acknowledged that study heterogeneity and a low number of RS block studies limited the strength of these findings. In a study of US-guided RS blocks using 20 ml of ropivacaine 0.25%, 0.5%, and 1%, peak plasma concentrations were dose-dependent and mean Tmax was 49.6, 48.5 and 38.1 min, respectively.10
Other complications
RSC entrapment by a surgical suture during abdominal closure11 and inadvertent injection of chlorhexidine (instead of LA) during single-injection RS block for repair of divarification of the recti have been reported.12 Reported complications of TAP blocks include liver haematoma and peritoneal placement, and these, along with bowel injury, are potential complications of RSC placement.13
RS haematoma is another potential complication of RS block secondary to vascular injury during needle or catheter placement. However, to our knowledge, there are no reports of RS haematoma associated with RSC analgesia.
RSC insertion techniques
RSCs can be placed before abdominal incision, during surgery with the abdomen open, or after surgery once the abdomen has been closed. They may be placed directly by the surgeon, inserted under US guidance, or by a combination of both techniques.2 Single-injection RS block using a ‘blind’ landmark-guided technique is well described, but this method is not commonly used for placement of catheters.14
Optimal timing and technique of RSC insertion are unclear but there are theoretical and practical advantages and disadvantages to each approach (Table 2). A recent randomised trial of paediatric patients undergoing umbilical hernia repair compared pre-incision US-guided RS block with surgical placement of RS block just before skin closure (without placement of RSCs).15 The authors found no difference in mean postoperative pain scores or morphine requirements, but mean operating room time was significantly longer (41 vs 35 min) for patients randomised to the US-guided RS block. Conversely, another randomised study of children undergoing umbilical hernia repair found pre-incision US-guided RS block reduced perioperative opioid use compared with LA infiltration of the surgical site.8
Table 2.
Advantages and disadvantages of rectus sheath catheter placement techniques. LA, local anaesthetic; RS, rectus sheath; US, Ultrasound
| Placement technique | Advantages | Disadvantages |
|---|---|---|
| US-guided insertion | Enables real-time confirmation of catheter placement within posterior RS May enable identification and avoidance of blood vessels within the RS Pre-incision RS block can be provided Can be performed in awake patient if original post-laparotomy analgesia inadequate |
Requires appropriate US equipment and skills Usually takes longer than surgical placement Catheters may exit skin within the surgical field if inserted pre-procedure and extended laparotomy incision required |
| Surgical insertion | Usually quicker to perform than US-guided placement No requirement for US equipment and associated skills Surgical placement is relatively straightforward to master Placement of catheters towards the end of surgery avoids them encroaching the surgical field |
Requires an open abdomen precluding pre-incision RS block Correct anatomical placement cannot be confirmed with some surgical insertion techniques Risk of LA leakage from posterior RS if surgical opening made into the posterior sheath Increased risk of needle stick injury |
Equipment
RSC insertion can be performed using equipment designed for epidural catheter placement—a 16 or 18 G Tuohy needle, epidural catheters, filters, and dressings. Pre-packaged kits with equipment for RSC placement are now commercially available. Echogenic Tuohy needles for US-guided catheter placement and multi-orifice catheters for LA infusion are also available, but whether they enhance the efficacy of RSC analgesia is currently unknown.
US-guided RSC insertion
General preparation for US examination
RSCs are typically placed when the patient is anaesthetised to reduce discomfort and abdominal wall movement during insertion and to optimise US image quality.
RSC insertion must be performed under aseptic conditions. With the patient positioned supine and the anaesthetist scrubbed, gowned, and gloved, the abdomen is prepared with antiseptic and drapes placed to provide a sterile field for catheter insertion. A high frequency (e.g. 13-6 MHz) linear array transducer with 50 mm footprint enables optimal identification of the relevant anatomical landmarks and adequate visualisation of needle placement in most patients. The transducer should be inserted into a sterile sleeve and sterile US gel used. The imaging depth is initially set at 4–6 cm but may need to be increased for the obese patient. For optimal ergonomics, the right-handed anaesthetist should stand to the left side of the patient with the US machine on the opposite side.
Sonoanatomy of the anterior abdominal wall
The US transducer is placed midline with transverse orientation approximately halfway between the umbilicus and xiphoid process to identify the mid-line linea alba. The transducer is moved laterally to observe the extent of the rectus muscle and associated anterior and posterior sheaths. The posterior sheath and transversalis fascia, commonly referred to as the ‘tramlines’, can be observed running along the posterior border of the rectus muscle (Fig. 3) It is important to identify blood vessels running within the sheath and rectus muscle. The peritoneum and loops of bowel below the sheath may also be observed (Fig. 3 online video).
Fig 3.
US image of the mid-rectus abdominis muscle. Arrow A: subcutaneous tissue; Arrow B: anterior rectus sheath; Arrow C: rectus abdominis muscle; Arrow D: transversalis fascia; Arrow E: posterior rectus sheath.
Supplementary video related to this article can be found at doi:10.1016/j.bjae.2018.03.002.
The following are the supplementary video related to this article:
Video S2US examination of the anterior abdominal wall. If reading the pdf online, click on the image to view the video.2
US-guided catheter insertion technique
Once an optimal US view is observed, the transducer is rotated 90º to the longitudinal orientation for catheter insertion. The appearance of the rectus muscle fibres will change as they are now running in-plane to the US beam, but the posterior sheath and transversalis fascia will remain visible as tramlines. A 20 ml syringe containing either saline or LA is attached to the needle. The needle is inserted in-plane to the US transducer. The needle is seen as it passes through the subcutaneous fat, anterior RS, and the rectus muscle until the tip lies just deep to the rectus muscle but anterior to the tramlines. Hydro-dissection separates the tramlines from the rectus muscle and creates a fluid-filled space in to which the needle can be advanced a centimetre or two to facilitate subsequent catheter insertion. The catheter is passed through the needle to leave approximately 6–8 cm within the RS (Fig. 4). The procedure is repeated on the opposite side, a filter attached to each catheter, and the catheters securely fixed to the abdominal wall (Fig. 5). The authors' preference is to place a BIOPATCH® (Ethicon, Inc., Somerville, New Jersey, USA), a chlorhexidine gluconate impregnated antimicrobial protective disc, over the catheter insertion site and secure the catheter using a LOCKIT Plus® (Smiths Medical ASD , Inc., Keene, New Hampshire, USA) catheter securement device over which a transparent dressing is applied. If surgical incision is likely to extend above the umbilicus and encroach on the catheter insertion sites, the catheters may need to be tunnelled laterally before fixation. The first dose of LA can now be administered if saline was used to aid catheter placement.
Fig 4.
US image showing insertion of RSC after hydrodissection of the posterior RS and transversalis fascia (tramlines) from the rectus muscle. Arrow A: subcutaneous tissue; Arrow B: anterior rectus sheath; Arrow C: rectus abdominis muscle; Arrow D: fluid deposited posterior to rectus abdominis; Arrow E: tip of catheter emerging from Tuohy needle; Arrow F: transversalis fascia; Arrow G: posterior rectus sheath; Arrow H: Tuohy needle passing through rectus abdominis muscle.
Fig 5.
Completed surgical placement of bilateral RSCs before laparotomy closure.
Surgical placement
Surgical placement of RSCs is performed when the abdomen is open by either percutaneously inserting a needle into the posterior RS or by directly making an opening into the posterior RS through which the catheters can be inserted. There is no evidence to support one technique over another. Percutaneous surgical placement with simultaneous US examination has also been described, with one study demonstrating that percutaneous surgical placement alone was inaccurate in 37% of patients with the peritoneum breached in 6%.2 RSC insertion immediately after abdominal wall incision enables early establishment of RS block. However, there is currently no evidence that timing of placement influences pain or subsequent analgesic requirements.
Percutaneous surgical placement technique
The percutaneous RSC placement technique favoured by the surgeons at the authors' institution is described in detail in the accompanying video (Fig. 5 online video).
Supplementary video related to this article can be found at doi:10.1016/j.bjae.2018.03.002.
The following are the supplementary video related to this article:
Video S3Surgical placement of rectus sheath catheters. If reading the pdf online, click on the image to view the video.3
Surgical placement via posterior RS incision
This technique involves surgically opening the posterior RS from within the abdomen.1 In theory this compromises the integrity of the RS and risks LA leakage during subsequent catheter dosing.
Delivery of RSC LA
The ideal LA delivery system should enable adequate spread of LA within the RS to provide effective analgesia along the entire length of the surgical incision. The method of delivery should not impair patient mobilisation, be safe, reliable, and cheap. There is no evidence supporting one particular LA solution or method of delivery. LA can be administered by manual intermittent top-up or via infusion pump(s). There are advantages and disadvantages to both techniques.
Manual LA administration may promote mobilisation as the RSCs are not connected to any pump. The catheters can be aspirated before injection to exclude intravascular placement and patients can be observed for side-effects or complications during and after LA injection. Disadvantages of this technique include the requirement for staff to administer the LA and potential inadvertent i.v. LA injection.
Infusion pumps used for RSC analgesia vary. They may be electronic or non-electronic (e.g. elastomeric) and may administer a continuous LA infusion, an intermittent LA bolus, or a combination of both. Reliable administration of a predetermined LA volume to each RSC requires two delivery devices—one connected to each RSC. The increased complexity of using two infusion pumps and potential impact on patient mobilisation can be mitigated to a degree by connecting the proximal ends of the two RSCs to a ‘Y’ connector that attaches to a single delivery device.1, 16 However, whether the same volume of LA is delivered to each RS using such a system is unknown.
A small study randomised patients with TAP catheters to continuous LA infusion (ropivacaine 0.2% 8 ml h−1 to each catheter) or intermittent LA bolus (ropivacaine 0.2% 20 ml to each catheter 8 hourly) after abdominal surgery and found no difference in pain outcomes.17 In the absence of evidence favouring one LA delivery method over another, centres providing RSC analgesia should chose a technique most suited to their own individual setting and resources.
LA regimens
RSC LA dosing regimens reported in the literature vary. The initial and subsequent manual LA bolus dose (for a 70 kg patient) at the authors' institution is: 20 ml ropivacaine 0.2% to both catheters 6 hourly. Alternative manual bolus regimens include: 20 ml bupivacaine 0.25%,1 or 20 ml levobupivacaine 0.25% 6 hourly to each catheter.17 Pump-delivered LA bolus regimens via a Y connector to both RSCs include: 40 ml ropivacaine 0.2% 4 hourly16 and 18 ml ropivacaine 0.5% 4 hourly.1 Continuous LA infusion of ropivacaine 0.2% at 8 ml h−1 via elastomeric pump connected to each RSC has been described.
Evidence of efficacy
The quality of the literature regarding RSC-related outcomes is generally poor and predominately consists of non-randomised, unblinded observational studies. There is large heterogeneity in methodology and a scarcity of trials that have assessed optimal insertion technique, LA delivery methods (including duration of catheter placement), longer term impact on chronic pain, and adverse events; and the effects compared with other analgesic techniques including thoracic epidural analgesia (TEA). Despite the limited studies of RSC techniques there are data, predominately in the paediatric literature, that support the efficacy of single-shot RS block.7, 8
Early observational studies of RSC analgesia for open urological and colorectal surgery suggested the technique was effective and safe.18, 19 A recent small randomised controlled trial compared US-guided RSC analgesia with TEA for midline laparotomy and found TEA was associated with lower morphine consumption in the first postoperative 72 h. However, pain scores were similar between groups and time to ambulation was significantly shorter in patients who received RSC analgesia.3 A much larger prospective randomised trial of RSC analgesia vs TEA for laparotomy is currently ongoing in the UK. The Thoracic Epidural analgesia versus Rectus Sheath Catheters (TERSC) trial aims to compare the efficacy, postoperative functional recovery, safety, and cost-effectiveness of the two techniques after elective open major abdominal surgery within an ERAS program.16
In a study of patients undergoing midline laparotomy for gynaecological oncological surgery, RSCs were surgically inserted (with US confirmation of correct placement) just before wound closure and subjects were randomised to receive 20 ml injections of LA (bupivacaine 0.25%) or normal saline every 6 h for 48 h. The authors found that patients in the LA group had significantly reduced pain and morphine consumption at 24 and 48 h compared with those in the saline group (mean morphine consumption 8.8 vs 27.3 mg and 14.8 vs 42 mg, respectively).2 However, a smaller trial that randomised patients to receive 20 ml bupivacaine 0.25% or 20 ml normal saline injection to RSCs placed at midline laparotomy found no difference in opioid requirement or pain scores.20 A recent study compared three types of continuous abdominal trunk blocks for analgesia after midline laparotomy for gynaecological oncological surgery (RSC, TAP catheter, and subcutaneous wound catheter analgesia) and found no difference in median morphine consumption on Day 2 (the primary outcome measure of the study). However, earlier opioid requirements and pain were higher in the subcutaneous compared with the TAP group.1
Finally, there is emerging evidence that supports the use of perioperative i.v. lidocaine infusion for postoperative analgesia.21 It is possible that LA systemic absorption may account for some of the beneficial effects seen with RS and other abdominal trunk blocks. However, no studies have so far compared these two analgesic techniques.
Conclusion
Despite the current lack of quality evidence regarding many elements of RSC analgesia, its increasing use and associated positive commentary suggest it is safe and may play a valuable role in enhancing recovery after major abdominal surgery. Technological advances and refinements in US devices, needles, catheters, and LA delivery systems will likely occur over coming years and may further improve outcomes associated with this analgesic technique.
Declaration of interest
None declared.
Acknowledgements
The authors would like to thank Professor Yee Leung for assistance in describing surgical placement techniques, and Mal Bruce and Sean Morton for help with video and image production.
MCQs
The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education.
Biographies
Matt Rucklidge FRCA FANZCA is a consultant anaesthetist in Perth, Western Australia. He has an interest in perioperative medicine and enhancing analgesia after major surgery.
Lizzie Beattie FRCA is a specialty registrar in anaesthesia in the West of Scotland School of Anaesthesia and has recently completed a fellowship in Perth, Western Australia.
Matrix codes: 1D02, 2G02, 3A03
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
US video clip of blood vessels posterior to the rectus abdominis muscle. If reading the pdf online, click on the image to view the video.
Video S2US examination of the anterior abdominal wall. If reading the pdf online, click on the image to view the video.2
Video S3Surgical placement of rectus sheath catheters. If reading the pdf online, click on the image to view the video.3